MDC Foundation: Giving everyone a chance to beat drugs

MDC Foundation Application

Name:
Address
Address:
City:
State:
Zip:
Phone:
Email:
How did you find out about us?

Marital Status:	Married Unmarried
Driver’s License #:
Driver’s License State Issued:

Date of Birth:
Sex:	Male Female
Do you have children?	Yes No
If yes, mention their age:

Is there a specific substance abuse program you would like to attend?

If yes, where & why?

Can you pay for your own treatment program?

If no, how much can you pay on a monthly basis?

What is your current job position and salary?

Do you have any other assets?

Do you have family financial support for a treatment program?

If yes, what is the relationship with the family member?

Family Member\Guardian’s name:

Phone Number
Have you previously been in a substance abuse program?

If yes, when & where?

Reason for leaving
Reason for treatment
What is your substance abuse addiction?

When is the last time you used an illegal substance?

Are you open to a faith based rehabilitation program?

Are you open to a year long treatment program?

Do you have any special needs?
Are there any warrants for your arrest?

Are you on parole?
Are you on probation?
Are you currently behind on child support?

Have you ever been in prison?

In your own words, why do you want to attend a substance rehabilitation program?

What are the main issues you believe you need to work on during the program?

Please list 3 references. Include Name, relationship, address and phone number.